an evaluation of the dialectical behaviour therapy programme in … · 2020. 6. 11. · an...

An Evaluation of the Dialectical

Behaviour Therapy Programme in

York and Selby, the Tees, Esk and

Wear Valleys NHS Foundation Trust

Rhian Hudson

Commissioned by Dr Pauline McAvoy, Clinical Psychologist (Tees, Esk and Wear

Valleys NHS Foundation Trust)

Service Evaluation Project Evaluation of the DBT programme in York and Selby

Prepared on the Leeds D.Clin.Psychol. Programme, 2019 2

Table of Contents

Introduction ........................................................................................................................ 4

1.1. Service Evaluation Context ................................................................................... 4

1.2. Literature Review ................................................................................................. 4

1.2.1. Borderline personality disorder (BPD) ............................................................. 4

1.2.2. What is dialectical behavioural therapy ............................................................ 4

1.2.3. DBT theory. ...................................................................................................... 6

1.2.4. Evidence supporting DBT................................................................................. 6

1.3. Rationale for Service Evaluation Project ............................................................ 8

1.4. DBT therapy in York and Selby ........................................................................... 8

1.5. Project Aims ........................................................................................................... 9

2. Methodology ................................................................................................................. 10

2.1. Design .................................................................................................................... 10

2.2. Participants ........................................................................................................... 10

2.3. Measures ............................................................................................................... 10

2.3.1. Quality of Life Measure .................................................................................. 11

2.3.2. Service Use Measure....................................................................................... 12

2.3.3. Clinical Symptom Measures ........................................................................... 12

2.4. Procedure .............................................................................................................. 12

2.5. Analyses ................................................................................................................ 13

2.6. Ethical Considerations ........................................................................................ 14

3. Results........................................................................................................................... 15

3.1. Descriptive Data ................................................................................................... 15

3.2. Analyses ................................................................................................................ 15

3.2.1. Quality of Life................................................................................................. 15

3.2.2. Use of Service ................................................................................................. 16

3.2.3. Clinical Symptom Presentation....................................................................... 19

4. Discussion..................................................................................................................... 22

4.1. Summary of Results ............................................................................................. 22

4.1.1. Hypothesis one ................................................................................................ 22

4.1.2. Hypothesis two................................................................................................ 22

4.1.3. Hypothesis three.............................................................................................. 22

4.1.4. Summary of results ......................................................................................... 23

4.2. Strengths and Limitations ................................................................................... 24

4.3. Dissemination ....................................................................................................... 25

4.4. Conclusions and Recommendations ................................................................... 25

5. References .................................................................................................................... 26



6. Appendices .................................................................................................................... 33

6.1. Appendix 1 – Measures Used .............................................................................. 33

6.2. Appendix 2 – SEP Recommendations ................................................................ 36



Introduction

1.1. Service Evaluation Context

In June 2016 the Tees Esk and Wear Valleys NHS Foundation Trust (TEWV) in

York and Selby established a Dialectical Behavioural Therapy (DBT) service for

individuals with emotional regulation difficulties, often associated with a diagnosis of

borderline personality disorder (BPD). Outcome data has been routinely collected to

monitor the impact of this therapeutic programme. This service evaluation project (SEP)

was commissioned to evaluate the impact of the York and Selby DBT therapy programme

on participants’ presenting difficulties and use of the service.

1.2. Literature Review

1.2.1. Borderline personality disorder (BPD). BPD is considered a complex and

severely impairing personality disorder that is costly to many mental health services

(Amner, 2012). BPD individuals can often experience intense emotional pain and distress

(Miller 1994; Perseius, Ekdahl, Åsberg & Samuelsson, 2005). Despite this, the literature

conveys negative stereotypes of manipulation and attention seeking behaviours (Brooke &

Horn, 2010; Fallon, 2003). Working with this client group can be challenging and requires

specific skills to engage clients and establish therapeutic relationships (Cleary, Siegfried,

& Walter, 2002; Horsfall, 1999; Koekkoek, Van Meijel, Schene, & Hutschemaekers, 2009;

Nehls, 2000; O’Brien & Flote, 1997).

Several psychotherapies have been found suitable in the management of BPD;

cognitive behavioural therapy (CBT), mentalization-based therapy, schema-focused

therapy, transference-focused therapy and DBT (Stoffers‐Winterling, Voellm, Rücker,

Timmer, Huband, & Lieb, 2012). Of these approaches, DBT has been studied the most and

is currently considered the most effective treatment for BPD (Stoffers‐Winterling et al.,

2012). In the UK, NICE guidelines (NICE, 2009) strongly advocated for the use of DBT

with BPD clients.

1.2.2. What is dialectical behavioural therapy? DBT was developed by Marsha

Linehan and is a structured time-limited, cognitive behavioural treatment used to address



suicidal behaviours associated with a diagnosis of BPD (Linehan, 1993a; 1993b; Linehan,

Armstrong, Suarez, Allmon, & Heard, 1991). DBT is considered the treatment of choice

for clients who experience intense emotions and deemed difficult to treat (Swales, Heard

& Williams, 2000). The DBT theoretical framework identifies BPD clients as those who

can be self-destructive, have difficulties with self and emotional regulation and lack

interpersonal and distress tolerance skills (Dimeff & Linehan, 2001). Consequently, DBT

purposely focuses on the following treatment goals: (1) decrease life-threatening suicidal

and parasuicidal acts; (2) decrease therapy-interfering behaviours (e.g., attendance,

homework compliance and aggressive behaviour); (3) decrease quality of life-interfering

behaviours (e.g., depression, substance abuse); and (4) increase behavioural skills; e.g.,

mindfulness, emotional regulation, and self-management (Linehan, 1993b; Linehan,

Tutek, Heard, & Armstrong, 1994).

There are three core principles that underpin DBT (Linehan 1993a). The first is

‘interrelatedness’, the dialectical philosophy emphasises relationships within and between

systems and the complexity of casual connections. The second is ‘opposition’, which states

reality is not static. This is where an individual is helped to find a solution for intense

emotions by engaging in problem solving skills, referred to as “wise mind thinking”

(Neacsiu, Ward-Ciesielski & Linehan, 2012, p. 1006). Finally, ‘change’ is identified as the

third principle central to DBT; which is the movement of the therapist and client through a

balance of acceptance and change (Neacsiu et al., 2012).

DBT includes one-to-one weekly sessions, skills group training as well as contact

with individual therapists in times of crisis. This represents four modes of intervention:

group therapy, individual psychotherapy, phone calls and consultation team meetings,

which run concurrently over a period of a year (O’Connell & Dowling, 2014). DBT skills

group therapy is designed to teach individuals skills to help them identify thoughts of self-

harm and develop alternative means for tolerating and managing distress There are four

sets of skills that are covered in the group therapy. Firstly, the skill of mindfulness is

introduced to help increase self-awareness and to promote benefits of focussing one’s

attention on the ‘here and now’, particularly enhancing one’s sensory awareness. Secondly,

interpersonal effectiveness skills are covered to promote an individual’s ability to

communicate more effectively with others. Thirdly, individuals are taught emotion



regulation skills which involves recognising emotions and how they may affect behaviour.

Finally, distress tolerance skills are developed to help individuals increase their ability to

tolerate feelings of distress and develop more effective skills to cope in situations of crisis

(McKay, Wood & Brantley, 2007).

1.2.3. DBT theory. The biosocial theory underpins the DBT framework. This

theory suggests that BPD is a dysfunction of emotional regulation (Linehan 1993a), the

ability to monitor, and manage one’s affective state (i.e., when and what emotions occur,

and how one experiences and expresses those emotions) in order to accomplish one’s goals

(Gross 1998; Thompson 1994). The biosocial theory believes individuals with BPD often

grow up within invalidating environments and therefore they lack many skills required to

cope with emotional regulation. There are several negative consequences of environments

that invalidate. Fraser and Solovey (2007, p.251) identify invalidating environments as

“emotional experiences and interpretations of events are often not taken as valid responses

to events; are punished, trivialized, dismissed or disregarded; and/or are attributed to

socially unacceptable characteristics such as over reactivity, inability to see things

realistically, lack of motivation, motivation to harm or manipulate, lack of discipline, or

failure to adopt a positive attitude”. In a healthy child/parent relationship, a child’s distress

is typically met with responsiveness and nurture. In an invalidating environment, a child’s

distress may be met with punitive words and an uncaring response. Consequently, these

children may grow up with limited skills needed to manage emotions and handle distressing

situations, leaving them unable to trust their own emotions or identify them (Linehan,

1993a). The biosocial theory also suggests there is a biological basis that can affect

individuals with BPD and therefore they may engage in self-destructive or harmful

behaviours to cope within stressful situations (Lynch, Trost, Salsman & Linehan, 2007).

This may relieve stress in the short-term by reducing painful emotions (Dimeff & Koerner,

2007).

1.2.4. Evidence supporting DBT. Several randomised control trials (RCT) have

shown strong evidence which supports the effectiveness and efficacy of DBT. The Koons,

Robins, Tweed, Lynch, Gonzalez, Morse, & Bastian (2001) study was one of the first that



compared DBT with a treatment as usual (TAU) groups in women diagnosed with BPD.

The DBT treatment time was shorter than Linehan et al’s., (1991) one year by six months,

and the skills training group and therapist consultation meetings were also shorter by 90

minutes each week. Koons et al., (2001) found a significant improvement in the women

who undertook DBT compared to those in the TAU group, in relation to four of the study’s

11 outcome variables (i.e., suicidal ideation, hopelessness, depression and anger).

However, similarly to Linehan et al’s., (1991) results, no significant change had been

identified in client hospital admissions for either DBT or TAU, as a result of the shorter

treatment time period of 6 months.

Another replication of Linehan et al’s., (1991) study conducted by Linehan,

Comtois, Murray, Brown, Gallop, Heard and Lindenboim (2006) examined an RCT of

DBT (n = 52) vs. treatment by ‘experts’ (CTBE) (n = 49) for suicidal behaviours and BPD.

Outcomes were measured as a baseline and at four monthly intervals during the treatment

period of 12 months, including a 12 month follow up. The results show DBT was more

effective than CTBE in preventing suicide attempts, reducing emergency department visits

and inpatient psychiatric admissions. DBT in this study was also found to be twice as

effective at maintaining people in treatment. Similar results have also been found in an

RCT study by Van den Bosch, Koeter, Stijnen, Verheul, and Van den Brink (2005). Despite

this, some studies have failed to support DBT’s efficacy. Carter, Willcox, Lewin, Conrad

& Bendit (2010) reported no significant differential reduction in deliberate self-harm or in

psychiatric hospitalizations using DBT. McMain, Links, Gnam, Guimond, Cardish,

Korman & Streiner (2009) also reported no significant differences in outcomes (frequency

and severity of suicidal and non-suicidal self-harm incidents) between two randomly

assigned groups of 180 patients with BPD to either DBT or general psychiatric

management.

More specifically, a number of studies evaluating DBT therapy programs report a

number of positive changes to client presenting difficulties shown across male and female

populations (Fieldman, Harley, Kerrigan, Jacobo & Fava, 2009; Soler, Pascual, Tiana,

Cebrià, Barrachina, Campins & Pérez, 2009; Waltz, Dimeff, Koerner, Linehan, Taylor &

Miller, 2009). These studies suggest clients who also undertook DBT therapy reported a

reduction in depression, anxiety, emotional intensity and irritability.



A number of systematic and Cochrane reviews have also contributed to the

increasing evidence supporting the use of DBT in clients with BPD (Linehan, 2014). Binks,

Fenton, McCarthy, Lee, Adams and Duggan, (2006) Cochrane review identified six studies

that focused on the treatment of BPD with DBT which had all reported reductions in

anxiety and depression levels, self- harm, hospital admission and use of prescribed

medication. However, this review also cautioned that the studies included used small

samples with few offering full confidence in their findings. More recently, Stoffers-

Winterling et al’s., (2012) review concluded that psychotherapy plays a substantial role in

the treatment of BPD. However, all of the treatments reviewed, including DBT, lacked a

strong evidence base.

1.3. Rationale for Service Evaluation Project

In 2016 TEWV undertook changes to its community mental health team (CMHT)

services. As a result, the trust established a DBT service within the York and Selby locality.

No evaluation of the York and Selby DBT service within TEWV has been undertaken

previously. Therefore, there is limited knowledge on the impact this DBT service has on

clients’ presenting difficulties and use of services within the York and Selby area. This

service evaluation will address this lack of knowledge.

1.4. DBT therapy in York and Selby

Clients were either offered 12-months DBT skills group, individual therapy

sessions and telephone coaching or 6-months DBT skills group, individual therapy sessions

and telephone coaching. While clients wait for DBT therapy they receive treatment as usual

(TAU) from TEWV Community Mental Health Team (CMHT). The DBT skills group

accepts up to 12 clients in each session, both men and women attend these groups lasting

2.5 hours with a break in the middle. As the DBT skills group is a rolling therapy

programme there are standard ‘group rules’, which participants are made aware of before

committing to therapy. Group facilitators have received a minimum of two days DBT

training with the majority of facilitators having received a more intense training program

of ten days.



1.5. Project Aims

The overall aim of this service evaluation is to examine the effects of the York and Selby

DBT therapy programme on participant quality of life, use of services (i.e. A&E and

inpatient services) and clinical symptom presentation.

The following three hypotheses will be examined:

1. Improvements will be seen in participants’ quality of life for both 6 month and 12

month group participants following the DBT programme.

2. Post DBT programme there will be a reduction in service use for both the 6

month and 12 month group participants.

3. Improvements will be seen in participants’ clinical symptom presentation for both

6 month and 12 month group participants.



2. Methodology

2.1. Design

This service evaluation project (SEP) used a quantitative methodology. A within-

subjects, repeated-measures design was used to investigate the project aim. The measures

used, justification for their use, and times of administration are summarised in Table 1.

2.2. Participants

The analysis was of data collected from the participants who attended the 6 month

and 12 month DBT groups in York and Selby that ran between 2016 to 2017. The inclusion

criteria for participants referred and accepted on to the York and Selby DBT service is as

follows:

• Have on-going difficulties with self-harm, or have experienced difficulty with this

in the last six months:

o Experience intense emotional distress and rapid mood change

o Interested and able to commit to therapy

o Not be crisis in order to ensure they can get the most out of therapy

Exclusion of participants occurred if there were missing or incomplete

questionnaire data.

2.3. Measures

Table 1. A list of measures used, measure justification and administration.

Measure used Reason for use Administered to

group one (6-

months DBT)

Administered

to group two

(12-months

DBT)

EQ-5D-3L To examine quality

of life

DBT assessment

session (T0), Pre

DBT (T1) and Post

DBT (T2)

DBT assessment

session (T0), Pre

DBT (T1), six

months in DBT

(T2) and Post

DBT (T3)



Service Use

Questionnaire

To capture client

contact with health

services

Pre DBT (T1) and

Post DBT (T2)

Pre DBT (T1)

and Post DBT

(T3)

Borderline Symptom

List (BSL-23)

To examine

severity of BPD

symptomatology

DBT assessment

session (T0), Pre

DBT (T1) and Post

DBT (T2)

DBT assessment

session (T0), Pre

DBT (T1), six

months in DBT

(T2) and Post

DBT (T3)

Inventory of

Interpersonal

Problems (IIP-32)

To examine

interpersonal

difficulties

Pre DBT (T1) and

Post DBT (T2)

Pre DBT (T1),

six months in

DBT (T2) and

Post DBT (T3)

Difficulties in

Emotion Regulation

Scale (DERS -36)

To examine

problems with

emotion regulation

Pre DBT (T1) and

Post DBT (T2)

Pre DBT (T1),

six months in

DBT (T2) and

Post DBT (T3)

The measures described in this section were collected for each participant for

service evaluation purposes by TEWV.

2.3.1. Quality of Life Measure. The EQ-5D-3L (EuroQol Research Foundation,

2018) is a 5-item self-report questionnaire commonly used to measure health-related

quality of life. Each item is divided into three levels of perceived problems (Level 1:

indicating no problem, Level 2: indicating some problems and Level 3: indicating extreme

problems). Scores are calculated using a five-digit health state profile that represents the

level of reported problems on each of the five dimensions of health. Health states were

determined using the Pareto Classification of Health Change (PCHC) approach (Devlin,

Parkin & Browne, 2010). An EQ-5D-3L health state is considered to be ‘better’ than

another if it is better on at least one dimension and is no worse in any other dimension. An

EQ-5D-3L health state is believed to be ‘worse’ than another if it is worse in at least one

dimension and is no better in any other dimension. Using this approach, a comparison was

carried out for each group across the administration time points (6-month DBT T0, T1 and

T2, and 12-month DBT T0, T1, T2 and T3). The following are ranked health states: ‘better’,



‘worse’, ‘exactly the same’, or, the changes in health are ‘mixed’: better on one dimension,

but worse on another. The measure is reported to have good internal consistency (α = 0.97).

2.3.2. Service Use Measure. The Service Use Questionnaire (SUQ) measure was

developed within the Leeds Personality Disorder Clinical Network (PDCN). The SUQ is a

9-item questionnaire that asks individuals to provide details of contact they have had with

services in the last 6 months. The SUQ is scored by asking individuals to answer ‘yes’ or

‘no’ to items to indicate whether there has been any involvement with services. This SEP

only used four items from the measure that focused on participant service use.

2.3.3. Clinical Symptom Measures. The Borderline Symptom List (BSL-23;

Bohus et al., 2009) is a 23-item self-report questionnaire that measures the severity of BPD

symptomatology. Each item is scored on a 5-point Likert scale, ranging from 0 (none) to 4

(very strong), total score is within the range of 0–92. Higher scores indicate more severe

borderline symptoms. The measure is reported to have good internal consistency (α = 0.97).

The Inventory of Interpersonal Problems measure (IIP-32; Barkham, Hardy &

Startup, 1996) is a 32-item self-report scale that measures interpersonal difficulties.

High scores indicate an increased level of interpersonal distress and difficulty. The

measure is reported to have good internal consistency (α = 0.86).

Difficulties in Emotion Regulation Scale (DERS; Gratz, & Roemer, 2004) is a 36-

item self-report measure that assesses problems with emotion regulation (total score range

between 36–180), high scores indicate greater difficulties with regulating emotions. The

measure is reported to have good internal consistency (α = 0.93).

Please see Appendix 1 for further details on the psychometric properties of each

measure used within this SEP.

2.4. Procedure

The data had been collected for routine service evaluation purposes. The reasons

for collecting outcome data had been discussed with each participant at each measure

administration stage. Participants were given the opportunity to discuss any questions or

concerns about outcome questionnaires and data with group facilitators. Participants were



informed they can decline to fill in outcome measures or opt out of this at any stage. As

this data was routinely collected as part of service outcomes, no written consent forms were

completed. A battery of five questionnaires (the EQ-5D-3L, BSL-23, IIP-32, DERS-36 and

the SUQ) were administered to clients (please refer to Table 1 for administration details).

2.5. Analyses

Data was first organised within a customised database, which was developed using

Microsoft Excel.

Descriptive statistics were undertaken on the EQ-5D-3L measure to identify

whether quality of life improved for participants that received either the 6 month or 12

month DBT programme. Descriptive statistics were also conducted to explore participant

use of service on the SUQ measure for both 6 month and 12 month groups post DBT

intervention.

Data was analysed using the Statistic Package for Social Sciences (SPSS) Version

25 (IBM Corp, 2017) to examine whether improvements to participants’ clinical symptom

presentation were evident for both 6 month and 12 month groups at different points of the

DBT programme as measured by the BSL-23, IIP-32 and the DERS-36.

6 month group. For the 6 month group, one one-way repeated measures ANOVA

was conducted to investigate whether improvements in participant BPD symptomology

were evident across three-time points throughout the DBT programme (assessment; T0,

pre DBT; T1 and post DBT; T2) as measured by the BSL-23 measure.

Two paired samples t-tests were also carried out for the 6 month group using SPSS

Version 25 (IBM Corp, 2017). The first paired samples t-test examined whether

improvements in participant interpersonal difficulties were present by comparing scores on

the IIP-32 measure pre and post DBT intervention. The second paired samples t-test

assessed whether there were improvements in participants’ emotional regulation by

comparing scores on the DERS-36 measure pre and post DBT therapy.

12 month group. For the 12 month group, three one-way repeated measures

ANOVA had been conducted to examine whether improvements to participant BPD

symptomology (measured by the BSL-23), interpersonal difficulties (measured by the



IIP-32) and emotional regulation (measured by the DERS-36) across four different time

points (assessment; T0, pre DBT; T1, during DBT; T2 and post DBT; T3) were studied.

The data met all the assumptions forthe s: the data were interval, and the

distribution of data was normal for all variables, using questionnaire administration time

as the independent variable and questionnaire score as the dependent variable, no

significant outliers were found and sphericity assumptions were all met.. The data also

met all the assumptions for the two conducted paired samples t-test: the data were

interval, and the distribution of data was normal for all variables, using questionnaire

administration time as the independent variable and questionnaire score as the dependent

variable and no significant outliers were found.

2.6. Ethical Considerations

This project was approved by the University of Leeds School of Medicine Research

Ethics Committee (SoMREC). Approval was granted by the ethics committee in February

2018, and by the Research and Development department at the relevant NHS Trust in May

2018.

To maintain confidentiality all identifiable information was removed prior to the

principal investigator receiving the data. Each participant was given a unique, personalised

participant code. All data files were password protected and stored on encrypted storage

devices.



3. Results

3.1. Descriptive Data

Routine data was collected from a total of 51 participants, with an average age of 34.6

years old. Forty-five (88.2%) were female, four (7.8%) were male and two (3.9%) stated

not otherwise specified. In terms of ethnicity, forty-seven (92.2%) were white British, two

(3.9%) stated white other, one (2%) stated not otherwise specified, and one (2%) specified

mixed other. There was a considerable number of limited and missing questionnaire data,

therefore this reduced the overall number of participants to 19 (37.2%); 10 participants

received 6-months DBT therapy and 9 participants received 12-months DBT therapy. Total

dropout rate was 25 (49.1%) participants and the total number of missing participant data

files was seven (13.7%).

3.2. Analyses

3.2.1. Quality of Life. Figures 1 and 2 show participant ranked quality of life

measured by the EQ-5D-3L across different time points for the 6-month (T0-T1 and T1-

T2) and 12-month group participants (T0-T1, T1-T2 and T2-T3).

6-month DBT therapy. The findings on the EQ-5D-3L for clients who undertook

6-month DBT therapy between T0 (DBT assessment) and T1 (pre) are as follows: two

participants presented as ‘better’, four ranked ‘worse’ in their health state, three

participants presented a ‘mixed’ health state and one participant’s health state stayed

‘exactly the same’. Examining EQ-5D-3L scores T1 (pre) and T2 (post) DBT therapy for

the 6-month group show four participants’ health states presented as ‘better’, two

participants stated ‘worse’, with two showing a ‘mixed’ health state and two participants

health states remained ‘exactly the same’ post treatment.

12-month DBT therapy. Health state results on the EQ-5D-3L for participants who

received 12-months DBT therapy between T0 (assessment) and T1 (pre) show two

participants presented with a ‘better’ health state, four participants’ health state had gotten

‘worse’ with three participants remaining ‘exactly the same’. EQ-5D-3L scores between

T1 (pre) and T2 (during DBT therapy) show four participants presented with a ‘better’



health state, two showed a much ‘worse’ presentation, with one participant with a ‘mixed’

health state with two participants presented with ‘exactly the same’ health state as T1 (pre).

The EQ-5D-3L scores between T2 (during DBT therapy) and T3 (post) demonstrate that

six participants presented with ‘better’ health states and three participants presented with a

‘worse’ health state.

3.2.2. Use of Service. Figures 3 and 4 show the total number of days service use

across 6-month and 12-month DBT participants pre and post DBT.

6-month DBT therapy. There was a reduction in the use of inpatient services, the

total number of days for the use of inpatient services reduced from 22 days to 12 days

post DBT. The use of the ICS service showed no change, participants reported zero days

in use of service for ICS pre and post DBT. For the use of A&E services, there was a

single day increase in total use post DBT therapy. As for the crisis service, the use of

service total days dropped from nine to six days post DBT treatment.

12-month DBT therapy. An improvement can also be seen post DBT in the use of

inpatient services, the total number of days use of service reduced from 33 days to 21 days

for participants who received 12-months therapy. Participants reported zero days for the

use of ICS services both pre and post treatment. In terms of A&E services, there was a

three-day reduction in use of service post DBT therapy as well as a reduction in the use of

crisis services post treatment, from 19 to nine days.

Descriptive statistics for measures BSL-23, IIP-32 and DERS-36 are shown in

Table 2 for participants that received 6-months DBT and in Table 3 for participants who

received 12-months DBT.



Figure 1. Showing participant ranked quality of life as measured by the EQ-5D-

3L across for 6-month participants across three time points.

Figure 2. Showing participant ranked quality of life as measured by the EQ-5D-3L

across for 12-month participants across three time points.

0

1

2

3

4

5

6

7

T0-T1 T1-T2 T2-T3

12 Month EQ-5D-3L Scores

Better Mixed Same Worse

0

1

2

3

4

T0-T1 T1-T2

6 Month EQ-5D-3L Scores

Better Mixed Same Worse



Figure 3. Showing total service use days for 6-month participants pre and post DBT

on the SUQ measure.

Figure 4. Showing total service use days for 12-month participants pre and post

DBT on the SUQ measure.

0

5

10

15

20

25

30

35

Pre Post

SUQ - 6 Month Participants Pre and Post DBT

Inpatient total days ICS total days A&E total days Crisis total days

0

5

10

15

20

25

30

35

Pre Post

SUQ - 12 Month Participants Pre and Post DBT

Inpatient total days ICS total days A&E total days Crisis total days



Table 2. 6-month DBT Therapy measure descriptive statistics.

Assessment

(T0)

Pre

(T1)

Post

(T2)

Measures n Mean SD Mean SD Mean SD

BSL-23 10 61.10 15.48 59.4 13.41 43.0 24.94

IIP-32 10 -- 2.09 .51 1.75 .67

DERS-36 10 -- 128.50 22.86 107.80 34.96

Note. -- = No data collected for this measure at time point, n = participant number, SD =

Standard Deviation.

Table 3. 12-month DBT Therapy measure descriptive statistics.

Assessment

(T0)

Pre

(T1)

During

(T2)

Post

(T3)

Measures n Mean SD Mean SD Mean SD Mean SD

BSL-23 9 68.33 15.85 67.88 9.45 57.44 16.97 45.0 20.78

IIP-32 9 -- -- 2.20 .39 1.99 .35 1.94 .33

DERS-36 9 -- -- 136.55 22.17 109.88 26.54 92.22 25.0

Note. -- = No data collected for this measure at time point, n = participant number, SD =

Standard Deviation.

3.2.3. Clinical Symptom Presentation

3.2.3.1. 6-month group data analyses. BSL-23. The results of the one-way

repeated-measures ANOVA show there was a non-significant main effect of time

on the severity of BPD symptomatology, F (2, 18) = 3.20, p = 0.065, ηp2 = .262

for participants who received 6-month DBT therapy. These findings suggest the 6-

month group average did not significantly reduce BPD symptomology as a result

of the DBT therapy.

IIP-32. Results of the paired samples t-test suggest a significant reduction

in interpersonal difficulties for participants when we compare pre DBT IIP-32



scores (M = 2.09, SD = 0.51) with post DBT IIP-32 scores (M = 1.75, SD = 0.67),

t(9) = 2.27, p < .005. Together this suggests on average the DBT therapy

programme had a positive impact at reducing interpersonal difficulties.

DERS-36. A paired samples t-test shows difficulty with emotional

regulation are lower when comparing participant pre DBT DERS-36 scores (M =

128.50, SD = 22.86) with post DBT DERS-36 scores (M = 107.80, SD = 34.96).

However, this change is not significant, t (9) = 2.05, p > .005. Suggesting

participant emotional regulation difficulties on average were not significantly

reduced following the 6-month DBT programme.

3.2.3.2. 12-month group data analyses. BSL-23. There was a significant

main effect of time on BPD symptomatology, F (3, 24) = 6.83, p = .002, ηp2 = .461

for these participants who received 12-month DBT therapy. Bonferroni post-hoc

analysis suggests the main difference lies between T0 (assessment) and T3 (post

DBT) (mean difference = 23.33, p = .023) as well as T1(pre DBT) and T3 (post

DBT) (mean difference = 22.88, p = .008) where the greatest reductions in BPD

symptomology can be seen compared to the other time points. This would suggest

that on average reductions in participant BPD symptomology occur following 12-

months of DBT therapy.

IIP-32. The results of the one-way repeated-measures ANOVA show there

was a non-significant main effect of time on interpersonal difficulties, F (2, 16) =

1.73, p = .209, ηp2 = .17 for these participants who received 12-month DBT

therapy. These findings suggest the 12-month DBT programme on average did not

reduce interpersonal difficulties for the 12 month group participants.

DERS-36. There was a significant main effect of time on participant

emotional regulation, F (2, 16) = 10.69, p = .001, ηp2 = .572 following 12-month

DBT therapy. Bonferroni post-hoc analysis suggests that the main difference lies

between T1 (pre DBT) and T3 (post DBT) (mean difference = 44.33, p = .004)

compared to T2 (during therapy) where the greatest reductions in emotional



regulation difficulties can be seen. These results suggest participants experienced

improvements in their emotional regulation following 12-months of DBT therapy.



4. Discussion

4.1. Summary of Results

The overall aim of this SEP was to examine the effects of the York and Selby DBT

therapy programme on participant quality of life, use of services (i.e. A&E and inpatient

services) and clinical symptom presentation. This SEP responds to the three proposed

hypotheses in the following ways:

4.1.1. Hypothesis one. Improvements will be seen in participants’ quality of life

for both 6 month and 12 month group participants following the DBT programme. In terms

of quality of life, the findings show that on average improvements were found for both 6

month and 12 month group participants following the completion of the DBT programme.

4.1.2. Hypothesis two. Post DBT programme there will be a reduction in service

use for both the 6 month and 12 month group participants. The SEP was also interested in

whether participant engagement in the DBT programme would reduce service use for both

6 month and 12 month group participants. Reductions in service use were found for both 6

month and 12 month group participants when comparing pre and post SUQ scores. These

results are suggestive that the DBT 6 month and 12 month programme is a cost-effective

psychological intervention for this client group within the York and Selby locality.

4.1.3. Hypothesis three. Improvements will be seen in participants’ clinical

symptom presentation for both 6 month and 12 month group participants. Analyses were

also carried out to examine whether improvements to participant clinical symptom

presentation were evident across time during the DBT programme for 6 month and 12

month group participants.

For the 6 month group participants, on average over time the DBT programme

significantly reduced participant interpersonal difficulties. The 6 month group participants

had also shown improvements in their BPD symptomology and emotional regulation,

however these improvements were not statistically significant.

For the 12 month group participants, analyses show on average participants BPD

symptomology and emotional regulation significantly reduced across the course of the

DBT programme. Despite improvements being seen in the participants’ interpersonal

difficulties were also present across time, such improvements were not statistically

significant.



4.1.4. Summary of results. In summary the overall results are mixed. It is

important to note that results were taken using 6 month and 12 month group averages and

therefore improvements in quality of life, service use and clinical symptomology were not

met for every participant within each of the two groups.

Despite mixed results, the findings do suggest both the 6-month and 12-month DBT

therapy programme offered by TEWV has clear benefits on psychological functioning for

some of its participants in their quality of life, use of service and clinical symptomology.

Furthermore, these findings are consistent with research showing DBT therapy reduces

service user presenting difficulties (Koons et al., 2001; Linehan et al., 1991 and Mc Main

et al., 2009).

Conversely, the positive effects for participants in completing either the 6-month

or 12-month DBT programme and how long these effects may last is difficult to determine

without follow-up data. However, the results here do challenge the perception of this client

group being ‘untreatable’ (see NICE, 2009) and support the application of DBT to people

with BPD presentations in the UK. Specifically these results are in line with previous

research showing that DBT is effective at reducing participant service use (Fieldman,

Harley, Kerrigan, Jacobo & Fava, 2009; Krawitz & Miga, 2019; Priebe, Bhatti, Barnicot,

Bremner, Gaglia, Katsakou, Molosankwe, McCrone & Zinkler, 2012; Soler, Pascual,

Tiana, Cebrià, Barrachina, Campins & Pérez, 2009).

The main goals of DBT therapy are to teach individuals how to live in the moment,

cope healthily with stress, regulate their emotions, and improve relationships with others,

taught through DBT specific strategies (mindfulness, distress tolerance, interpersonal

effectiveness and emotion regulation). The findings show some of these DBT strategies

have been effective and suggest the 6-month and 12-month DBT programme is helping

clients to manage some of their presenting difficulties. It is, however, also worth noting

that despite the current SEP findings, it is difficult to know whether the results were solely

related to the therapy or whether there were other factors that could have impacted this,

such as major life changes, therapist, duration of therapy or client motivation that occurred

during the course.



4.2. Strengths and Limitations

A key strength of this SEP is that it is the first comprehensive overview of the York

and Selby DBT therapy service within the TEWV NHS Trust. Nonetheless, the study is

not without its limitations.

First, there was no control group. This reduces the certainty as to whether the

observed effects are a result of either the 6-month DBT, 12-month DBT or other factors.

Second, the sample size was much smaller than originally anticipated due to

missing questionnaire data related to participant measure adherence and dropout. This can

contribute to the likelihood of more extreme scores being present and thus a

misrepresentation of true pre and post treatment scores. As a result, the data was checked

for extreme outliers, none were found.

Third, the present SEP reviewed data from very few men and therefore gender bias

could be a contributing factor to the overall findings. This bias is a factor that is not just

frequently reported upon within the DBT literature (Feldman, Harley, Kerrigan, Jacobo &

Fava, 2009; Lynch, Morse, Mendelson & Robins, 2003; Waltz, Dimeff, Koerner, Linehan,

Taylor & Miller, 2009) but also found within a number of other fields of research across

the UK (Holdcroft, 2007). However, DBT is a treatment that was devised for reducing

parasuicide by women with BPD (Linehan, 1987) and therefore further research should be

considered before utilising DBT with clients who do not fit this clinical picture.

In addition, the measures used were self-report with no additional clinician reports.

This would have been helpful to gain additional information on the effects of DBT therapy

for both groups of participants.

Furthermore, due to the limitations of conducting analyses focusing on participant

group averages, future evaluations may wish to consider analyses based upon a case-series

design.

Finally, due to the quantitative nature of this SEP, conclusions cannot be drawn

about client experiences of DBT therapy. Further qualitative investigation would be

required to explore this. Finally, more data time points had been collected for participants

who received 12-months DBT than the participants that received 6-month DBT therapy.

This limits our knowledge on treatment effects during DBT therapy for the 6-month DBT

participants as there was no ‘during treatment’ data collected for this group.



4.3. Dissemination

The findings from this SEP were disseminated at the University of Leeds SEP

conference, and will be disseminated to the Research and Development (R&D) department

and the commissioner at TEWV NHS Foundation Trust.

4.4. Conclusions and Recommendations

Overall the findings from this service evaluation are mixed, presenting

improvements in some but not all of participants’ presenting difficulties. The

improvements highlighted above are however statistically significant and meaningful,

suggesting the DBT programme can improve presenting difficulties for some clients. As a

result of the current findings, and conscious of the current SEP strengths and weaknesses,

the following recommendations have been made for future evaluations:

• DBT therapists to re-visit regularly the purpose of collecting routine outcome data

with clients throughout the programme and check for completed questionnaire data.

This will reduce missing data and ensure larger data samples are collected.

• To collect qualitative data and clinician reports to further examine effectiveness of

York and Selby DBT therapy service.

• Including additional data collection time-points (e.g. client discharge and follow-

up data).

For the full SEP recommendations please see Appendix 2.



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6. Appendices

6.1. Appendix 1 – Measures Used

EQ-5D-3L

EQ-5D-3L (EuroQol Research Foundation, 2018). A 5-item measure used as a brief quality

of life measure. The EQ-5D-3L descriptive system comprises of the following five

dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression.

Each dimension has 3 levels: no problems, some problems, extreme problems. The

respondent is asked to indicate their health state by ticking (or placing a cross) in the box

against the most appropriate statement in each of the 5 dimensions.

The measure is reported to have good internal consistency (α = 0.97). For further details

on the psychometric properties of the EQ-5D-3L please see EuroQol Research Foundation

(2018).

Service Use Questionnaire (SUQ).

This measure was developed within the Leeds Personality Disorder Clinical Network

(PDCN). The SUQ is a 9-item questionnaire that asks individuals to provide details of

contact they have had with services in the last 6 months. The SUQ is rated by asking

individuals to answer ‘yes’ or ‘no’ to items to indicate whether there has been any

involvement with services.

If items are scored as ‘yes’, individuals are asked to provide the number of days they

received involvement from services. Please note that the current SEP was only interested

in the initial 4 items of the SUQ as requested by the SEP commissioner. This is due to the

fact that the participants would primarily come into contact with inpatient, day hospital

(ICS), accident and emergency (A&E) and crisis team services. This measure is not a



standardised measure and there is no research detailing the psychometric norms for this

questionnaire.

Borderline Symptom List

Borderline Symptom List (BSL-23; Bohus et al., 2009). A 23-item measure that asks

is a self-rating instrument using a Likert scale rating (0 = ‘not at all’, 1 = ‘a little’, 2 =

‘rather’, 3 = ‘much’, and 4 = ‘very strong’). This measure asks participants to rate their

symptoms specific to those of borderline-typical symptomatology for the past week. It was

created from the original BSL-95, which was developed in 2007, based on a sample of 379

borderline patients (Bohus et al., 2007).


on the psychometric properties of the BSL-23 please see Bohus et al., (2009).

Inventory of Interpersonal Problems

Inventory of Interpersonal Problems (IIP-32; Barkham, Hardy & Startup, 1996) is a 32-

item self-report scale that identifies a participant’s prominent interpersonal difficulties on

a likert-scale and produces an overall score across eight subscales;

domineering/controlling, vindictive/self-centred, cold/ distant, socially inhibited/avoidant,

non-assertive, overly accommodating/exploitable, self-sacrificing/overly nurturant,

intrusive/needy.


on the psychometric properties of the IIP-32 please see Barkham, Hardy and Startup,

(1996).



Difficulties in Emotion Regulation Scale

Difficulties in Emotion Regulation Scale (DERS; Gratz, & Roemer, 2004). The DERS is a

brief, 36-item, self-report questionnaire that measures multiple aspects of emotion

dysregulation across six scales derived through factor analysis: nonacceptance of

emotional responses (nonacceptance), difficulties engaging in goal directed behaviour

(goals), impulse control difficulties (impulse), lack of emotional awareness (awareness),

limited access to emotion regulation strategies (strategies), lack of emotional clarity

(clarity).


on the psychometric properties of the DERS please see Becerra et al., (2013).



6.2. Appendix 2 – SEP Recommendations

• Self-report involving risk and harm to self has been reviewed in items included in

the BSL-23, DERS and IIP-32. Many studies on DBT group therapy have

demonstrated reductions in risk of harm to self, but few have examined changes in

risk of harm to others. Given the co-morbidities and behavioural profiles of those

referred to standard NHS community mental health services, future service

evaluation may benefit from looking at the effectiveness of DBT group therapy in

reducing risk of harm to others. This could be done by including the CORE-OM

measure (Evans, Connell, Barkham, Margison, McGrath, Mellor-Clark & Audin,

2002).

• To consider ways to recruit and retain more males in DBT group therapy. This

might be done by providing a male only DBT group therapy.

• Systematically replicate this service evaluation, on an annual basis to gain a larger

sample size and consider findings in the context of existing evaluations.

• Group facilitators to re-visit the purpose of collecting routine outcome data with

clients at various points during the DBT therapy to check for completed

questionnaire data reducing the risk of missing data that will ensure larger data

samples for future evaluations.

• Future service evaluations may wish to also collect qualitative data and clinician

reports to further examine effectiveness of York and Selby DBT therapy service.

• The use of additional time-points for data collection to include discharge from the

service and follow-up is strongly recommended to review client progress over time

to be evaluated.

• Consider the use of a psychometric instrument such as the Group Session Rating

Scale (Duncan & Miller, 2007) as a way of reviewing group and facilitator

feedback, supporting team dynamics that can be discussed safely in the weekly

DBT consult meetings.

• It is suggested a future evaluation of the service be conducted and consider the

above recommendations.

an evaluation of the dialectical behaviour therapy programme in … · 2020. 6. 11. · an...

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